Claim {{ claim.claim_number }}
{% if claim.status == 'DRAFT' %}
{{ claim.get_status_display }}
{% elif claim.status == 'SUBMITTED' %}
{{ claim.get_status_display }}
{% elif claim.status == 'UNDER_REVIEW' %}
{{ claim.get_status_display }}
{% elif claim.status == 'APPROVED' or claim.status == 'PARTIALLY_APPROVED' %}
{{ claim.get_status_display }}
{% elif claim.status == 'DENIED' %}
{{ claim.get_status_display }}
{% elif claim.status == 'PAID' %}
{{ claim.get_status_display }}
{% else %}
{{ claim.get_status_display }}
{% endif %}
{{ claim.get_priority_display }} Priority
{{ claim.get_claim_type_display }}
{{ claim.patient.get_full_name }} ({{ claim.patient.mrn }}) | Service Date: {{ claim.service_date|date:"F d, Y" }}
Patient Information
{{ claim.patient.get_full_name }}
{{ claim.patient.mrn }}
{{ claim.patient.date_of_birth|date:"F d, Y" }}
{{ claim.saudi_id_number|default:"Not provided" }}
{{ claim.patient.phone_number|default:"Not provided" }}
{{ claim.patient.email|default:"Not provided" }}
Insurance Information
{{ claim.insurance_info.insurance_company }}
{{ claim.insurance_info.policy_number }}
{{ claim.insurance_info.get_plan_type_display|default:"Not specified" }}
{{ claim.insurance_card_number|default:"Not provided" }}
{{ claim.authorization_number|default:"Not required" }}
{{ claim.insurance_info.get_insurance_type_display }}
Service Information
{{ claim.service_provider }}
{{ claim.service_provider_license|default:"Not provided" }}
{{ claim.service_date|date:"F d, Y" }}
{{ claim.facility_name|default:"Not specified" }}
{{ claim.facility_license|default:"Not provided" }}
Medical Information
{{ claim.primary_diagnosis_code }}
{{ claim.primary_diagnosis_description }}
{% for diagnosis in claim.secondary_diagnosis_codes %}
{% endif %}
{% if claim.procedure_codes %}
{{ diagnosis.code }} - {{ diagnosis.description }}
{% endfor %}
{% for procedure in claim.procedure_codes %}
{% endif %}
{% if claim.notes %}
{{ procedure.code }} - {{ procedure.description }}
{% endfor %}
{{ claim.notes|linebreaks }}
Attached Documents ({{ documents.count }})
{% for document in documents %}
{% endfor %}
{% if document.mime_type == 'application/pdf' %}
{% elif 'image' in document.mime_type %}
{% elif 'word' in document.mime_type %}
{% else %}
{% endif %}
{{ document.title }}
{{ document.get_document_type_display }} •
{{ document.file_size|filesizeformat }} •
{{ document.uploaded_at|date:"M d, Y g:i A" }}
{% if document.description %}
{{ document.description }}
{% endif %}
Financial Summary
{{ claim.billed_amount|floatformat:2 }}
Billed Amount (SAR)
{{ claim.approved_amount|floatformat:2 }}
Approved Amount (SAR)
{{ claim.paid_amount|floatformat:2 }}
Paid Amount (SAR)
{{ claim.patient_responsibility|floatformat:2 }}
Patient Responsibility (SAR)
Approval Rate
{{ approval_percentage|floatformat:1 }}%
Status History
{% for history in status_history %}
{{ history.changed_at|date:"M d, g:i A" }}
{% empty %}
{% endfor %}
{% if history.from_status %}
{{ history.get_from_status_display }} → {{ history.get_to_status_display }}
{% else %}
{{ history.get_to_status_display }}
{% endif %}
{% if history.reason %}
{{ history.reason }}
{% endif %}
{% if history.changed_by %}
{{ history.changed_by.get_full_name|default:history.changed_by.username }}
{% endif %}
No status history available
Quick Actions
{% if claim.status == 'DRAFT' %}
{% elif claim.status == 'SUBMITTED' %}
{% elif claim.status == 'UNDER_REVIEW' %}
{% elif claim.status == 'APPROVED' %}
{% endif %}
View Patient Back to Claims
View Patient Back to Claims